Utilization Management Representative I
Core
Coordinating cases for precertification and prior authorization review, managing incoming claims, and conducting clinical screening processes.
Role type
Utilization Management Representative I
Builds
Prior authorizations, inpatient/outpatient precertifications, and post-service requests for health plans.
Domain
Healthcare administration / Insurance
Required skills
Customer service, call center operations, contract and benefit eligibility determination, data entry, clinical screening, multi-tasking, digital tools proficiency
Preferred skills
Medical terminology, insurance field experience, problem-solving, analytical skills
Responsibilities
Managing incoming calls and post-service claims; determining contract and benefit eligibility; authorizing inpatient admission and outpatient precertification; referring cases requiring clinical review; identifying and entering referral requests into the UM system; responding to inquiries from clients and providers; conducting clinical screening; authorizing initial session sets to providers; checking benefits for facility-based treatment.
Seniority
Entry-level, non-management